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Aims: To estimate the proportion eligible for lipid-lowering therapy (LLT) when using the systemic coronary risk estimation 2 (SCORE2) on apparently healthy individuals.

Methods and results: Individuals aged 50-64 years were randomly invited to The Swedish Cardiopulmonary Bioimage Study (n = 30 154). Participants with previous atherosclerotic cardiovascular disease (CVD), diabetes mellitus, or chronic kidney disease were excluded. The 10-year risk of CVD was estimated using the SCORE2 equation and the multicell chart. Eligibility for LLT was estimated according to the 2021 European Society of Cardiology CVD prevention guidelines. Presence of coronary atherosclerosis was determined using coronary computed tomography angiography (CCTA). Among 26 570 apparently healthy individuals, 32% had high and 4% had very high 10-year CVD risk, according to the SCORE2 equation. Among high- and very-high-risk individuals, 99% had low-density lipoprotein cholesterol levels above guideline goals making 35% of the total population eligible for LLT. Of those eligible, undergoing imaging, 38% had no signs of coronary atherosclerosis according to CCTA. Using the SCORE2 chart, 52% of the population were eligible for LLT, of which 44% had no signs of coronary atherosclerosis. In those with high or very high risk, ongoing LLT was reported in 7% and another 11% received LLT within 6 months after study participation.

Conclusion: Nearly all apparently healthy individuals with high and very high CVD risk, or 35% of the total population, were eligible for LLT according to guidelines, and a large proportion had no signs of atherosclerosis. Compared with the SCORE2 equation, the SCORE2 chart resulted in more individuals being eligible for LLT. What proportion of an apparently healthy middle-aged population would be eligible for lipid-lowering therapy (LLT) according to the 2021 European Society of Cardiology (ESC) guidelines when using systemic coronary risk estimation 2 (SCORE2)? What proportion of those eligible for LLT have atherosclerosis according to coronary imaging? According to the guidelines, nearly all individuals categorized as high and very high risk according to the SCORE2 equation, or 35% of the total population, were eligible for LLT, of which 38% had no signs of coronary atherosclerosis. These proportions increased when the SCORE2 multicell chart was used. Implementing SCORE2 and the ESC guidelines would result in more than one in three apparently healthy middle-aged individuals being eligible for LLT. A significant proportion would have no signs of coronary atherosclerosis.